Microsoft word - ct screening form.doc

First Name:__________________________ M.I. _____ Last Name:____________________________ Male / Female D.O.B:_________________ Employer: _____________________________ MARRIED / SINGLE / OTHER Home Phone: _______________________ Cell: _____________________ Work: ________________________
Address: ____________________________City/State/Zip Code: _____________________________________________
Primary Cardholder’s Name on Insurance: ________________________________ Relation: Self / Spouse / Child
Subscribers D.O.B: __________ Subscribers Employer:___________________________ SS#:_____________________
Please answer the following questions. For your safety, please circle Yes or No and answer completely:
Have you had a prior CT scan that pertains to today’s exam and where? ________________________________________
What medications do you currently take?________________________________________________________________
What is your weight? ____________________________
List any surgeries?__________________________________________________________________________
Yes No Are you Allergic to Iodine? List all Drug/Food Allergies you have:
Yes No Have you had any IV contrast within the past 48 hours? ________________________________
Yes No Do you have both kidneys? ______________________________
Yes No History of Kidney Surgery? ______________________________
Yes No Asthma or Lung problems? ______________________________
Yes No Hepatitis or Jaundice? __________________________________
Yes No Epilepsy/Seizures? _____________________________________
Yes No High Blood Pressure (hypertension)? _______________________________________________
Yes No Heart Problems? _______________________________________________________________
Yes No History of Cancer; If yes, explain:___________________________________________________
Yes No Stomach/Intestinal Problems; If yes, explain: __________________________________________
Yes No Multiple Myeloma; If yes, explain: __________________________________________________
Yes No Stroke; If yes, explain: ___________________________________________________________
Yes No Bladder Problems; If yes, explain: __________________________________________________
Yes No Metal Implants/Foreign Objects; If yes, explain: _______________________________________
Yes No DIABETIC OR RENAL DISEASE? _____________________________________________________
WHAT ARE YOUR SYMPTOMS? ______________________________________________________________
If Diabetic, do you take Metformin Medications (Glucophage, Glucovance, Avadament, Metaglip, Fortamet, or Riomet)?
PLEASE NOTIFY YOUR PHYSICIAN FOR ADVISEMENT*******************************************
FOR FEMALE PATIENTS OF CHILD BEARING AGE; COMPLETE THE FOLLOWING: Please check all that apply; if none please complete below information: I have had a Hysterectomy I have had a tubal ligation Are you Pregnant? Yes / No Are you Nursing? Yes / No Birth Control Information (If Applicable): My birth control method is ___________________________. The dates of my last menstrual cycle are/were ___________________ to _______________________. Consent: I have answered all the questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that I am NOT pregnant at this time. Patient Signature: _______________________________________________ Date: ____________________________ ________________________________________________________________________________________________ FOR TECH USE ONLY: CREATININE _____________ IV SITE: ___________ GAUGE: ___________ TECH: ____________


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